DEMOGRAPHICS. Female Weight: lbs
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1 DEMOGRAPHICS Date of Birth: Age: years Gender: Male Height: inches Female Weight: lbs Handed: Right BMI: Left Ambidextrous Race: choose only one Ethnicity: Marital Status: African American / African Heritage American Indian or Alaskan Native Asian Central / South Asian Heritage Asian East Asian Heritage Asian Japanese Heritage Asian South East Asian Heritage Native Hawaiian or Other Pacific Islander White Arabic / North African Heritage White / Caucasian / European Heritage Hispanic or Latino Not Hispanic or Latino Single Married Domestic Partner Widowed Other page 1 of 8
2 MEDICAL HISTORY Social History Tobacco Use: mark only one: Packs per day: Years: Types: Date Quit: Never Cigarettes Quit 1 10 Pipe Passive Cigars Yes 2 20 Snuff Chew Alcohol Use: Drug Use: No No Use per week: Yes Yes 1 Drinks per week: 2 Can(s) of beer IV Drug Use: 5 Drink(s) containing 0.5 oz of alcohol No 10 Glass(es) of wine Shot(s) of liquor Yes Are you currently working? What is or was your occupation? Yes No Is this a work related problem? Yes No If yes, list your OWCP Claim # or L&I Claim # If disabled, when did you last work? Is a lawyer invovled with this problem? If Yes, name/address: page 2 of 8
3 MEDICAL HISTORY CONTINUED Family History Please check if any of your family members have had the following: ADHD Colorectal Cancer Lipids Alcohol / Drug Diabetes Osteoporosis Allergic /Atopic Disease Gastrointestinal (GI) Psych Arthritis Genitourinary (GU) Pulmonary Autoimmune Heart Stroke Cancer Hypertension Thyroid Other: Past Medical History Do you have, or are you being treated for, any of the following (please check all that apply): Allergic rhinitis Heart attack (MI) Anxiety Hepatitis (please specify type(s)) Asthma High blood pressue (HTN) Bipolar High cholesterol Bleeding/clotting disorder Psoriasis Cancer Rheumatoid Arthritis (RA) Chemical dependency Drug Stroke Alcohol Transient ischemic attack (TIA) Chronic lung disease/emphysema (COPD) Thyroid disorder Hypo Congestive heart Failure (CHF) Hyper Coronary artery disease (CAD) Sleep Apnea Depression Other sleep disorder Diabetes Using insulin (IDDM) Ulcers Stomach ulcers Not using insulin (NIDDM) Peptic ulcer disease (PUD) Fibromyalgia Other (specify) Heartburn Reflux (GERD) NO PAST MEDICAL HISTORY page 3 of 8
4 MEDICAL HISTORY CONTINUED Allergies 1. Do you have any allergies? Yes No If yes, please list. To Medications? To Foods? 2. Are you allergic to latex? Yes No 3. Are you allergic to iodine? Yes No Medications 1. Are you taking any pain medications? Yes No If yes, please list all. Pain Medications Dose Times per day Reason for taking 2. All other Medications Dose Times per day Reason for taking page 4 of 8
5 MEDICAL HISTORY CONTINUED Review of Systems Do you or have you had any of the following problems? (check all that apply) General weight gain insomnia weight loss fever fatigue night sweats/chills Eye glasses/contacts glaucoma cataracts Ear/Nose/Throat sinus trouble ringing in ears hearing loss Heart/Vascular myocardial infarction (MI) high blood pressure congestive heart failure (CHF) irregular heartbeat peripheral vascular disease chest pain coronary disease fluttering in chest Lung shortness of breath lung disease difficulty breathing persistent cough chronic obstructive pulmonary disease (COPD) emphysema Stomach/Liver decreased appetite diarrhea constipation hepititis heartburn Cirrhosis nausea Muscles/Bones arthritis sprains fractures Urinary Tract kidney stone prostate problems bladder/kidney infections painful urinating Skin masses non healing wounds blisters dermatitis Neurology seizures numbness tingling severe headaches balancing problems strokes / TIAs Mental Health anxiety dementia depression other (please describe) Endocrine diabetes diet controlled increased thirst diabetes oral medication thyroid diabetes using insulin Blood/Lymph bleeding problems enlarged lymph nodes clotting problems lymphoma anemia leukemia Immunological HIV/AIDS hay fever Sjogrens lupus scleroderma Cancer under treatment metastatic Location: currently disease free Comments page 5 of 8
6 MEDICAL HISTORY CONTINUED Surgical History What studies have you had for this problem? (check all that apply) X rays CT MRI Arthrogram Nerve Study (EMG) Bone Scan Other: Have you had any previous surgeries for this problem? Yes No Surgeries for this problem Did it help Surgeon Year List all Other Orthopaedic Surgeries Please list/check all Other Surgeries [Bone/Joint/Ligament/Soft Tissue] Surgeries Year Surgeries Year No previous surgeries Appendix (appendectomy) Gall bladder (cholecystectomy) Bypass/open heart (CABG) Hernia repair Hysterectomy Tonsils removed (tonsillectomy) Other Surgeries Year page 6 of 8
7 MEDICAL HISTORY Chief Complaint: History of Present Illness Location where is the problem located? Right Side Left Side Both Sides Neck Spine Shoulder Elbow Wrist / Hand Hip Knee Ankle / Foot Other Severity please rate the intesnity of your joint pain/discomfort: (1 = no pain, 10 = severe pain) Context how did this problem begin? Modifying Factors What makes your symptom(s) worse? Using affected side Work Exercise Don't know What improves your symptoms? Rest Ice Heat Exercise NSAIDS (anti inflammatories) page 7 of 8
8 TREATMENT AND STATUS Primary Procedure Secondary Procedure Procedure: date: Surgeon: Reason/Mechanism: Procedure: date: Surgeon: Reason: Patient Notes: wound complications: infection: physical therapy: other relevant: Patient Notes: wound complications: infection: physical therapy: other relevant: Weight Bearing: (status/time) Function: Weight Bearing: (status/time) Function: Narcotics Rx: Yes No Narcotics Rx: Yes No when off: Return to Work: Workers' Compensation Status: when off: Return to Work: Workers' Compensation Status: Follow up Imaging: Yes Follow up Imaging: Yes No No page 8 of 8
UW Medicine. Affix Pt Label Here. Name: U Number: DOB: New Shoulder & Elbow Patient Form
New Shoulder & Elbow Patient Form UW Medicine Name Date Age How did you hear about us? Requesting Physician Name UPIN # Address City State Zip Code Phone Fax email Primary Care Physician Name UPIN # Address
UW Medicine. Address City State Zip Code Phone Fax
New Warme Patient Form Name Date Age Please Check one: Right Handed Left Handed Ambidextrous How did you hear about us? Requesting Physician Name UPIN # Address City State Zip Code Phone Fax email Primary
All Other Medications, Dose Times per day Reason for taking the medication. Phone #
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VASCULAR SURGERY PATIENT HEALTH HISTORY
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*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
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Patient Information. Insurance Information
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I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
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P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Patient Enrollment Sheet
Patient Enrollment Sheet PATIENT INFORMATION: LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE CELL PHONE WORK PHONE E-MAIL ADDRESS EMPLOYER YOUR OCCUPATION
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to